Provider Demographics
NPI:1922781061
Name:MCGOUGH, FREDANNA M'CORMACK (CHES, PHD)
Entity Type:Individual
Prefix:PROF
First Name:FREDANNA
Middle Name:M'CORMACK
Last Name:MCGOUGH
Suffix:
Gender:F
Credentials:CHES, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SANCROFT LN
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7589
Mailing Address - Country:US
Mailing Address - Phone:618-203-1023
Mailing Address - Fax:
Practice Address - Street 1:205 SANCROFT LN
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7589
Practice Address - Country:US
Practice Address - Phone:843-349-2991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL13905174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator